Modified Benefit Formula Questionnaire-Employer

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 205(c)(2), 215(a)(7), and 215(d)(3) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may delay a determination of any Social Security benefits and could result in a referral to the Internal Revenue Service.

We will use the information to verify the claimant’s statements about employment and make a determination of eligibility for Social Security benefits. We may also share this information for the following purposes, called routine uses:

1. To employers or former employers, including State Social Security administrators, for correcting and reconstructing State employee earnings records and for Social Security purposes;

2. To specified business and other community members and Federal, State, and local agencies for verification of eligibility for benefits under section 1631(e) of the Social Security Act; and

3. To student volunteers, individuals working under a personal services contract, and other workers who technically do not have the status of Federal employees, when they are performing work for the Social Security Administration, as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned Agency functions.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System; 60-0089, entitled Claims Folders Systems; and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.